Medical Ethics

Dr. Murali VallipuranathanMBBS (Jaffna), PGD (Population Studies), MSc, MD (Community Medicine)

Consultant Community Physician, Ministry of HealthVisiting Lecturer, Universities of Jaffna & Colombo

PhD Scholar, King’s College, London

Learning Objectives

• What is medical ethics?• What are the generally accepted principles of

medical ethics?• How have medical ethics developed to the

form we know today?• What are codes of medical ethics, and which

ones do we follow?

Ethics

• Is Branch of philosophy• Is the study of morality • are not laws, but standards of

conduct which define the essentials of honorable behavior by a group or institution

Defining our Terms

• Morality - our belief about right and wrong (usually subjective and unexamined).

• Ethics - (a) the study of principles for choosing right action when doing right may also involve doing harm or wrong; (b) the use of ethical theory to choose the best course of action; (c ) the study of what is good and bad in human character and conduct.

Medical Ethics

• Medical ethics deal with the moral principles which should guide members of medical profession in their dealings with one another, with their patients and with their State.

Ethics and law

ETHICS LAW

Law and medical ethics share the goal of creating and maintaining social good and have a symbiotic relationship

Components of Medical Ethics

• The Physician -- Patient Relationship• The Physician -- Physician Relationship• The relationship of the Physician to the System

of Healthcare• The Relationship of the Physician to Society

THE PRINCIPLES IN MEDICAL ETHICS

• The Principle of Non-Maleficence• The Principle of Beneficence• The Principle of Autonomy• The Principle of Veracity• The Principle of Confidentiality(or Fidelity)• The Principle of Social Responsibility and

Justice

The Principle of Non-Maleficence

• first do no harm• sanctity of life• calculated risk or risk benefit

The Principle of Beneficence

• do only that which benefits the patient• patient’s welfare as the first consideration• care consideration competence

The Principle of Autonomy

• right to information and self determination• free and informed consent• free will and accord - intentional participation

in treatment• respect and dignity maintained

The Principle of Veracity

• Truth telling• Obligation to full and honest disclosure

The Principle of Confidentiality

• Based on loyalty and trust• Maintain the confidentiality of all personal,

medical and treatment information• Information to be revealed with consent

and for the benefit of the patient• Except when ethically and legally required• Disclosure should not be beyond what is

required

The Principle of Justice and Social Responsibility

• Actions are consistent, accountable and transparent

• not to discriminate on age, sex, religion, race, position or rank

• greater good of society• respect of the Law• equity and distribution of burden & benefits

Conflicts of Ethical Principles

autonomy

veracity

confidentiality

paternalism

nonmaleficence

justice

beneficence

research

dual obligations family interest

payer's interest

What is an Ethical Dilemma?

• A conflict between moral imperatives, i.e., “what is the right thing to do?”– What is “medically” right vs. patient preference

• Jehovah’s Witnesses and transfusions– What is preferred by patient vs. proxy decision maker

• Rights of minor vs. legal guardians– What is best for patient vs. what is best for society

• Commitment laws, notification of sexual partners of patients with HIV

Why study ethics?Ethical DilemmaSituations necessitating a choice between two

equal (usually undesirable) alternatives.•Should a parent have a right to refuse

immunizations for his or her child? •Should children with serious birth defects be kept alive?•Should a woman be allowed an abortion for any reason?

Resolution of Ethical Dilemmas

• Principles• Ethical codes• Clinical judgement• Reasoned analysis• Ethical committees• Ethical tests

• Declarations• Oaths & Pledges• Common sense• Debate• Ethical Consults• The Law

Current Operative Principles of Medical Ethics

• The Principle of Make-more-money-ence

• The overriding principle of all physician behavior, this above all dictates patient care decisions.

Current Operative Principles of Medical Ethics

• The principle of Don’t-get-sued-ience

• Second only to make-more-money-ence, this most important principle is behind many unnecessary tests and consults.

Current Operative Principles of Medical Ethics

• The Principle of Turficence

• Learned early in med school or residency, this principle requires the physician to always ask the question, “could I turf this patient to someone else?”

Current Operative Principles of Medical Ethics

• The Principle of Distributive Justice

• Distribute the blame of your failure to as many other people as possible, including the patient.

Current Operative Principles of Medical Ethics

• The Principle of Malevolence

• The more of a jerk you are to the staff, the farther you’ll go.

• Screaming and yelling is a perfectly acceptable practice and has a long, proud tradition in medicine.

Medical Ethics• Long history

– Third Dynasty (Egypt) 2700 BCE– Code of Hammurabi (Babylon) 1750 BCE: If the physician succeeds, he

gets paid. If he fails, at worst he loses his hands.– Oath of the Hindu Physician (Vaidya’s Oath) 15th cy. BCE– Hippocratic oath (Hippocrates, ca 460-370 BCE)– The Oath of Asaph and Yohanan (ca 6th cy. CE)– Advice to a Physician (Persia) 10th cy. CE – Oath of Maimonides 12th cy. CE– Ming Dynasty (China) 14th cy. CE– Seventeen Rules of Enjun (Japanese Buddhist Physicians) 16th cy. CE)

Drawn from Codes of Medical and Human Experimentation Ethics by Victoria Berdon and Jennifer Flavin viewable at http://wisdomtools.com/poynter/codes.html

History cont.• Percival's Code (England) 1803 basis for first AMA Code of Medical Ethics. • Beaumont's Code (United States) 1833: experimental treatments when all else

fails. Get voluntary, informed consent. Stop experiment at subject’s request. • American Medical Association (AMA) Code of Medical Ethics 1847 • Claude Bernard (France) 1865 • Walter Reed (United States) 1898: Introduces written consent “contracts”.

Allows healthy human subjects in medical experiments. • Berlin Code, or Prussian Code (Germany) 1900: No medical experiments when

subject not competent to give informed consent, in the absence of unambiguous consent, or when information not properly explained to subject.

• Reich Circular (Germany) 1932 Concerned with consent and well-being of the subjects.

Drawn from “Codes of Medical and Human Experimentation Ethics” by Victoria Berdon and Jennifer Flavin viewable at http://wisdomtools.com/poynter/codes.html

Modern Issues and statements• Nuremberg Code (1947)

– Medical research• Declaration of Geneva, W.M.A. (1948, 1968, 1984, 1994, 2005, 2006)

• World Medical Association International Code of Medical Ethics• AMA revision (1957)• Declaration of Helsinki, application to medical research (1964, rev. 1975,

1983, 1989, 1996, 2000)

• Belmont Report (1979)• AMA revision (2001)

Drawn from “Codes of Medical and Human Experimentation Ethics” by Victoria Berdon and Jennifer Flavin viewable at http://wisdomtools.com/poynter/codes.html

Key Moments in History of Medical Ethics

• The Hippocratic texts display a sustained appreciation for the limits of medicine and the need to prevent unnecessary iatrogenic harm to the sick

• The Art– “... I will define what I conceive medicine to be. In

general terms it is to do away with the sufferings of the sick, to lessen the violence of their diseases, and the refuse to treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless.”

Key Moments in History of Medical Ethics • Central themes of the Hippocratic texts

– Hippocratic physicians were in a crowded, harsh, and unforgiving medical market place

– Physicians and other practitioners with high mortality rates faced failure and poverty

• Reputation for being a good physician, whose patients die only from their incurable diseases and injuries, becomes paramount

– Leaving off the care of the dying becomes a matter of urgent self-interest and good reputation

• My patients die from their incurable diseases and injuries, not anything that I do

– Prognosis emerges in the Hippocratic text as the central clinical skill of the physician

Key Moments in History of Medical Ethics

• Scottish physician-ethicist, John Gregory (1724-1773), wrote the first modern work on professional medical ethics in the English language– Used philosophy of medicine and philosophical

ethics to reform medicine into a profession• Gregory changed the ethical standard of care

for dying patients

Key Moments in History of Medical Ethics

• John Gregory, Lectures on the Duties and Qualifications of a Physician (1772)– “Medicine, or the art of preserving health, of

prolonging life, of curing diseases, and of making death easy.”

Key Moments in History of Medical Ethics

• Thomas Percival (1740-1804) was an English physician best known for crafting perhaps the first modern code of medical ethics. He drew up a pamphlet with the code in 1794 and wrote an expanded version in 1803, in which he reportedly coined the expression "medical ethics”

• Percival's Medical Ethics served as a key source for American Medical Association (AMA) code, adopted in 1847.

Nuremberg Trials

See anyone we know?

Key Moments in History of Medical Ethics

• The International Military Tribunal of 1946, convened by the U.S., British, French and Soviets, which convicted the major Nazi leaders who survived World War II

AND• Twelve cases tried by U.S. military tribunals at

Nuremberg from1946-9 of groups of doctors, lawyers, industrialists, Einsatzgruppen and more.

Key Moments in History of Medical Ethics

• Nuremberg Code of Ethics:– Informed Consent mandatory and exercised freely– Experiments must avoid physical and mental

suffering– Experiments must be avoided if death or disabling

injury a possibility– Information from Nazi experiments is taboo

Medical Codes

• Professional ethics of codes• Developed through a process of collaboration,

consensus, and finally codification• Notion of professional self-regulation

AMA’s Code of Medical Ethics

1847 Edition 2001 Edition

The duties of a doctor registered with the General Medical Council

Patients must be able to trust doctors with their lives and well-being. To justify that trust, we as a profession have a duty to maintain a good standard of practice and care and to show respect for human life. In particular as a doctor you must:

– make the care of your patient your first concern; – treat every patient politely and considerately; – respect patients' dignity and privacy; – listen to patients and respect their views; – give patients information in a way they can understand; – respect the rights of patients to be fully involved in decisions about their care; – keep your professional knowledge and skills up to date; – recognise the limits of your professional competence; – be honest and trustworthy; – respect and protect confidential information; – make sure that your personal beliefs do not prejudice your patients' care; – act quickly to protect patients from risk if you have good reason to believe that you or a colleague

may not be fit to practise; – avoid abusing your position as a doctor; and – work with colleagues in the ways that best serve patients' interests.

In all these matters you must never discriminate unfairly against your patients or colleagues. And you must always be prepared to justify your actions to them.

The duties of a doctor registered with the Sri Lanka Medical Council

• (i) I will pledge my life to the service of humanity•

(ii) I will give primary consideration to the health of the patient and I will not use my profession for exploitation and abuse of the patient

•(iii) I will practise my profession with conscience, dignity, integrity and honesty.

•(iv) I will respect the secrets which are confided in me even after the patient has died.

Reference: http://www.island.lk/index.php?page_cat=article-details&page=article-details&code_title=55292

The duties of a doctor registered with the Sri Lanka Medical Council (continued)

• (v) I will give to my teachers the respect and gratitude which is their due.

•(vi) I will maintain the noble traditions of the medical profession.

•(vii) I will not permit considerations of religion, nationality, race, party politics, caste or social standing to interfere with my duty as a doctor.

•(viii) I will maintain the utmost respect for human life from its beginning. deal and Reality

What constitutes unethical behaviour (professional misconduct)?

• * Neglect or disregard by doctors of their professional responsibilities. (medical neglect)

•* Abuse of professional privileges or skills.

•* Derogatory (or degrading) professional conduct.

•* Advertising and canvassing.

•* Commenting maliciously on professional colleagues.

How SLMC act on a reported professional misconduct?

• In investigating allegations of serious professional misconduct, the SLMC goes through a quasi-judicial procedure.

• If a doctor is found guilty of serious professional misconduct, Section 33 of the Medical Ordinance enacted in 1927 empowers the SLMC to erase the name of the guilty doctor from the medical register.

• This means that such a doctor cannot legally practice medicine.

Confidentiality

• Not a single ethical principle in itself, rather it is linked in to several bioethical principles.

• Confidentiality shows a respect for an individual's autonomy and their right to control the information relating to their own health.

• In keeping information about the patient secret the doctor is acting beneficently.

When may a Dr break confidentiality

• where serious harm may occur to a third party, whether or not a criminal offence, e.g. threat of serious harm to a named person

• where a doctor believes a patient to be the victim of abuse and the patient is unable to give or withhold consent to disclose

• where, without disclosure a doctor would not be acting in the overall best interests of a child or young person who is his/her patient and incapable of consenting to disclosure

• when, without disclosure the task of preventing or detecting a serious crime by the police would be prejudiced or delayed

When may a doctor break confidentiality

• when, without disclosure the task of prosecuting a serious crime would be prejudiced or delayed (e.g. a patient tells you that he killed someone several years ago)

• where a doctor has a patient who is a health professional and has concerns over that person’s fitness to practice and posing a serious danger to patients in his or her care

• where a doctor has concerns over a patient’s fitness to drive.

Living Wills• Every adult with mental capacity has the right to agree to or refuse

medical treatment. • Living wills can be use to make clear a person advance wishes.• They include general statements about a person’s wishes and

specific refusals of treatment called advance directives.• Set out which treatments the person would or wouldn't like to

receive should they lose mental capacity in the future.• Advance statements aren't legally binding, but health professionals

do have to take them into account when deciding on a course of action. Family and friends can also use them as evidence of the person’s wishes.

Doctrine of Double effect• Some interventions can create a positive outcome

while also potentially doing harm. • The combination of these two circumstances is

known as the "double effect." • Use of morphine in the dying patient can ease the

pain and suffering of the patient, while simultaneously hastening the demise of the patient through suppression of the respiratory drive.

Providing contraception without parental consent to patients under 16 year old

• the young person will understand the professional's advice; • the young person cannot be persuaded to inform their

parents; • the young person is likely to begin, or to continue having,

sexual intercourse with or without contraceptive treatment; • unless the young person receives contraceptive treatment,

their physical or mental health, or both, are likely to suffer; • the young person's best interests require them to receive

contraceptive advice or treatment with or without parental consent

Medical Certificates

must include :true information, correct accurate data. Also the physician must not give certificate to

anyone or without seeing the person. Also the physician must be sure of the identity of the patient in case of age estimation certificate and the certificate show the finger prints to release himself of the responsibility of partnership of such fraudulent act.

Informed Consent

• Implementation of the ethical principle of autonomy• Accords individuals the option of accepting or refusing medical

treatment• Informed consent doctrine confers two separate and connected

rights:– The right to receive adequate information to make an intelligent choice

about whether to accept or refuse a proposed treatment– The right to refuse medical treatment for any reason, including quality of

life based on the specific individuals judgment. – To be considered legally valid, refusal of treatment must be based upon

an informed decision of the patient, after s/he has received all information material to making such a decision.

Informed ConsentOrigins of the Informed Consent Doctrine• Right to be free from nonconsensual interference with one’s person • Morally wrong to force one to act against his or her will• Serves six functions

– Protect individual autonomy– Protect patient status as human being– Encourage physicians to carefully consider decisions– Avoid fraud or duress– Foster rational decision-making by patients– Increase public involvement in medicine

Informed ConsentLegal framework for Informed Consent • Historically was based on “Battery Theory”

– Unwanted touching– Not operative today in almost all jurisdictions– May be operative if there is no consent at all (i.e. operating on the wrong

knee)• Negligence: Operative in virtually all jurisdictions

– Prima facie case based on:• Duty to disclose information• Failure to disclose (unless statutory exception met)• If information had been disclosed, patient would not have consented to

procedure• Injury and damages

Informed Consent

Duty to disclose standards• Professional Standard

– Physician has disclosed information that a reasonable or prudent doctor would have disclosed under similar circumstances

• Patient-need standard– What a reasonable person would want to know; information that would

be material to a patient• States with statutes usually adopt the “Professional Standard”• Case law is split 50-50 on which standard to follow

Informed Consent

What must be disclosed • The condition or diagnosis• Nature and purpose of treatment• Risk of treatment• Treatment alternatives which includes:

– Things that are already known– Things that everybody should know– Option of no treatment– All alternatives do not have to be disclosed

Informed ConsentExceptions to the General Rule of Disclosure• Patient is unconscious or otherwise incapable of consenting

(Emergency treatment)– Harm from failure to treat is imminent– Outweighs any harm threatened by proposed treatment

• Therapeutic Privilege– Risk disclosure poses such a threat of detriment to a patient as to become

unfeasible or contraindicated from a medical point of view– Does not accept the paternalistic notion that the physician may remain

silent because divulgence might prompt the patient to forego therapy the doctor believes the patient must receive

Thank you